Provider Demographics
NPI:1740464106
Name:TRAVIS, JACK S (LMSW)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:S
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 MEDEA WAY
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-4540
Mailing Address - Country:US
Mailing Address - Phone:631-987-2751
Mailing Address - Fax:
Practice Address - Street 1:80 SAXTON AVE
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-2610
Practice Address - Country:US
Practice Address - Phone:631-987-2751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-20
Last Update Date:2011-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0766321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical